The Widening Gap in Physician-Patient Relationships

The physician-patient relationship is a bedrock of the U.S. health system. Strong relationships are associated with higher ratings for physicians and better outcomes for patients but there’s a catch.

In Secretary of Health and Human Services’ Tom Price Senate confirmation and many times since, he has vowed his administration will seek to restore that relationship. But what patients associate with a strong relationship is increasingly at odds with how physicians think. And the gap between the two seems to be widening.

Background:

Per the American Medical Association, the physician-patient relationship is a formal or inferred relationship between a physician and a patient, which is established once the physician assumes or undertakes the medical care or treatment of a patient. It is a responsibility physicians don’t take lightly and most believe they do it well.

The physician-patient relationship has been widely studied. A framework developed by Ezekiel and Linda Manuel has been widely used to categorize the four roles physician play in these relationships: guardian, technical expert, counselor, and friend. In interacting with patients, physicians play all four. Researchers have linked a physician’s personality with their bedside manner. Surveys show most physicians lean toward a more paternalistic approach in dealing with patients and the majority think friendships with patients must be approached with caution. Academics have studied the dynamic between physicians and patients, observing that the physician is the ‘power’ figure in most. Studies have linked a physician known to have a prickly personality with more patient complaints and, in some specialties, a higher susceptibility to lawsuits. And physicians routinely compare notes among themselves about problem patients with whom interactions are routinely difficult.

Through the years, the American Medical Association and every major medical organization have opined consistently to the need for strong physician-patient relationships. Physicians understand their importance: they’re pragmatists. They understand that a pleasant bedside manner is not necessarily correlated to clinical competency and skillfulness but both are important. They are sensitive to impressions that their profession attracts smart people with big ego’s and a predisposition toward arrogance. And they recognize that changes in their environment are driving a wedge between how they practice and the expectations patients have for the relationship. Consider:

·       More physicians are now practicing in larger groups, and one third are employed in hospitals (MGMA). That means the clinical judgement of a clinician often is part of a larger scheme for managing patients consistently (to optimize clinical coordination) and efficiently (to maximize productivity and revenues). Peer reviews, utilization management and comparative effectiveness are now part of their lexicon.

·       Data about the quality of a physician’s care is increasingly accessible to patients from independent third-parties that sponsor report cards about physician outcomes, practice patterns and ratings by patients. It’s a growing irritant to physicians, especially those that believe the measures used are neither valid or reliable.

·       The science of medicine—what works, what doesn’t and for which patients—is increasingly accessible to patients seeking information about treatments that might not be recommended by their physician. The democratization of medical knowledge via social media and readily accessible clinical guidelines from reputable sources means patients have more questions and are often armed with inaccurate or harmful information.

·       Physician income pressures are mounting. Granted, their incomes remain healthy compared to the overall population ranging from 3:1 up to 20:1 but physicians face higher administrative costs and lower reimbursement from employers and insurers. There’s almost universal belief among physicians they’re fairly paid and palpable fear things are getting worse. And they react viscerally to the notion that physician greed is systemic.

·       And physicians understand that ratings by patients are here to stay. Patients expect to be able to compare the quality of medical care they receive just as they compare every other high-profile profession. And physicians know their ratings matter to payers like Medicare who penalize them for poor patient experience ratings.

Against this backdrop, most physicians believe their relationships with patients are less than ideal due to circumstances beyond their control. The majority think the profession is being compromised by external intrusions that limit their effectiveness as clinicians and compromise their relationships with patients.  They want to spend more time with patients but recognize the gap between their wishes and reality is widening.

Patients see a gap, but their perspective is different. They see their physicians in positions of power and trust who are highly compensated and knowledgeable. They do not understand the complexities of modern medical practice nor do they believe them insurmountable. Their wish list is simple:

·       Most patients trust their physicians’ judgement but want a second opinion for major treatments and decisions, and they pursue those on their own.

·       Most want to learn more about their condition from sources that are evidence-based and independent.

·       Most believe they should have complete access to their own medical record without cost or hassle.

·       Most think their physicians should leverage online technologies to allow online scheduling, tele-visits, secure messaging and more. (Most practices permit online bill payment and little more).

·       Most want their physicians to embrace alternative therapies and lifestyle interventions in their recommendations.

·       All want their physician to tell them what a procedure or encounter will cost ahead of time to avoid surprises.

·       All want to know their physician’s track record—outcomes, patient ratings, and more.

·       All want their clinicians to disclose their conflicts of interest i.e. business relationships influence their referrals.

·       All want their physicians to treat them with respect and listen better.

·       All think their practices should provide better service that’s convenient, accessible and person-centered.

Little wonder half of all patients say they are open to making a change. Most think physicians are focused on their own needs rather than theirs.

What’s Ahead for Physician-Patient Relationships?

Four trends will reshape physician-patient relationships:

·       Practice settings: Physicians will increasingly be affiliated with larger groups that position themselves around their depth, breadth, service, prices and reputation.

·       Financial Incentives: Physicians and patients will share financial risks associated with health insurance plans, and Medicare will penalize physicians that do not score at acceptable patient satisfaction levels. In other words, physicians will have an incentive to manage a patient relationship rather than accommodate visits and requests.

·       Data: An abundance of valid and reliable data will be available to consumers to compare the performance of their physicians about outcomes, practice patterns, financial relationships, patient experiences and costs.

·       Insurance Design: Patients will have more skin in the game. Employers are shifting financial responsibility to employees via high deductible plans; Medicaid is shifting to managed Medicaid and Medicare is encouraging alternative payment programs.

The combined impact of these means physician-patient relationships will be better coordinated, managed tightly and the basis for differentiating the performance of medical practices. Patients will migrate to practices that put their needs and values first.

The gap in the physician- patient relationship is widening. It’s clear patients want something quite different than they’re getting. Both perspectives are important and neither more than the other. So as Secretary Price and others espouse the centricity of the physician-patient relationship, it’s important it be understood objectively.

Paul

P.S. This past week, I spent two days with Veterans as part of a No Barriers program in Asheville NC. I journaled what I heard in passing: Recounting his IED encounter, one said “In one instant, I went from hero to zero”. Another said “in 2009, I realized I had to get on with living or get on with dying”. And much more. I learned about the co-dependence of Veterans’ Benefits and Veterans Health programs and their importance to these patriots. Rich, Erik, Mark, Dave, Matt and Juan: thank you for your service. Thank you for helping me and others pause to appreciate the true meaning of courage and patriotism.

Resources: the physician-patient relationship

Physician Roles: Ezekiel J. Emanuel and Linda L. Emanuel.  "Four Models of the Physician-Patient Relationship." JAMA 267:2221-6, 1992

MaryJo Ludwig, MD and Wylie Burke, MD PhD “Physician-Patient Relationship: Ethics in Practice” University of Washington 2014 http://depts.washington.edu/bioethx/topics/physpt.html

Patient Views: “62% are concerned with being able to pay for medical treatment if they get sick or injured…48% are not confident they could afford care should they become seriously ill…28% have skipped a medical test, treatment or follow-up or avoided a visit to the doctor in the past 12 months because of costs…27%. avoided filling a prescription in the past 12 months due to costs” (Harris Poll survey of 1511 adults who had seen their primary care physician twice in the prior year on behalf of the Physicians Foundation, February 2016)

Deloitte Center for Health Solutions annual survey of U.S. Health Consumers www2.deloitte.com/us/en/pages/life-sciences-and-health-care/articles/center-for-health-solutions-survey-of-us-consumers-health-care.html

Ethics in Physician-Patient Relationships: Chapter One: The AMA Code of Ethics www.ama-assn.org

Patient Interest in Telehealth: Harris Poll 2017 of 2200 U.S. adults on behalf of American Well http://go.americanwell.com/2017ConsumerSurvey.html

·       64% of American adults (and 74% of Millennials) are willing to have a video consultation with a physician. They associate video consults with greater diagnostic accuracy and lower costs.

·       70% of consumers prefer to receive common prescriptions through a video consultation, 63% want to refill prescriptions over video, 41%would want antibiotics, 30 percent would want blood pressure medication and 27 percent would want allergy or asthma medication.

·       17 million Americans would switch physicians if they offered video consultations.

Hospital Ratings of their Physicians: Questions used by polling firm Press Ganey to ask patients about their “providers”:

·       Did this provider explain things in a way that was easy to understand?

·       Did this provider listen carefully to you?

·       Did this provider give you easy to understand instructions about taking care of these health problems or concerns?

·       Did this provider seem to know the important information about your medical history?

·       Did this provider show respect for what you had to say?

·       Did this provider spend enough time with you?

The news recap from last week:

·       For the past week, the spotlight has been on Hurricane Harvey and its devastating impact in the Houston-St. Charles areas. The death toll stands at 50 (as of Sunday) with more expected. The restoration costs and timeline for recovery is indeterminable but one thing’s evident: the first responders, volunteers and the hospitals and caregivers who stepped up make us all proud. For a moment, we were all one nation!

·       The FDA approved its first gene therapy: Novartis’ Kymriah for B-cell acute lymphoblastic leukemia. In 63 cases in children and young adults, it had an 83% success rate. A dose will cost $475,000 which the company says is less than the cost of bone marrow transplants that run $540,000 to $800,000.  

·       CMS announced it is cutting funds for patient navigators and advertising in the 39 Healthcare.gov states citing poor results from 2015 spending. Grants to the nonprofits that supply navigators will fall by 40% to $36.8 million this year and advertising will drop by 90 % to $10 million.

·       Optum, the information and health-services division of UnitedHealth Group Inc., announced Tuesday it will acquire the Advisory Board Co.’s health care business for $1.3 billion. The deal is part of a two-step sale: private-equity firm Vista Equity Partners will acquire The Advisory Board Co.'s education business for roughly $2.6 billion.

·       The Third Circuit appeals court ruled in favor of Pfizer and Wyeth concluding they had not violated pay-to-delay rules for delayed generic competition for their Lipitor and Effexor brands.

·       Carolinas HealthCare System and UNC Health Care signed a letter of intent to merge, creating combined organization with $14 billion in annual operating revenue. And seven-hospital network Pinnacle Health based in Harrisburg announced it was joining University of Pittsburgh Medical Center system. Under the deal announced Friday, UPMC Pinnacle will retain a local 12-member governing board, with UPMC adding six members. UPMC Pinnacle hospitals will also honor contracts with regional insurers not affiliated with UPMC and its health plan.

·       And Congress returns to DC this week with a full slate: finalizing the FY18 federal budget, expanding the federal debt ceiling, funding for Harvey, et al. And the Senate Health Education Labor and Pensions Committee begins hearings to stabilize the individual insurance markets before the November 1 enrollment begins.